Clinical documentation: Use amendments carefully

Q. How do amendments to documentation work?
Friday, January 24, 2014

A. It’s interesting to see how the industry has changed regarding documentation.  When I first started consulting and would ask how many people were actively requesting documentation up front, not many would raise their hands. Now, most people are requesting it and holding physicians accountable, despite Medicare not doing so. Transferring the responsibility of educating physicians on Medicare documentation requirements to suppliers is completely contradictory to Medicare’s long stance that suppliers are not clinicians. However, they are held responsible for educating and relying on the clinical documentation of others.

It’s not enough to collect documentation. The supplier must review it and determine if it will pass very strict adherence to complex policies. The risk is great and the liability lies with you. Thus come amendments, which are a perfectly acceptable practice in clinical documentation, if done properly. The principles that must be followed are: 1.) clearly and permanently identify any amendment, correction or delayed entry as such; 2.) clearly indicate the date and author of any amendment, correction or delayed entry; and 3.) do not delete but, instead, clearly identify all original content. If these principles are met, then it is valid.  

Another important reminder is that medical necessity must be established prior to the equipment being dispensed. In that respect, auditors would be precluded from considering any documentation dated after the date of service in question. If you wait to get amendments until you receive an ADR letter, it’s not going to help you. If you do it prior to dispensing products, particularly more expensive items or items that require a KX modifier, then you lessen your risk.

Wayne van Halem is president of The van Halem Group. Reach him at 404-343-1815 or